Nerve Conduction Velocity (NCV) & Electromyography (EMG) Studies

Nerve Conduction Velocity (NCV) & Electromyography (EMG) Studies [Preauthorization Required] Medical Policy: MP-ME-09-09 Original Effective Date: November 5, 2010 Reviewed: November 5, 2010 Reviewed: November 2, 2011 This policy applies to products subscribed by the following corporations, MCS Life Insurance Company (Commercial), and MCS Advantage, Inc. (Classicare) and, provider s contract, unless specific contract limitations, exclusions or exceptions apply. Please refer to the member s benefit certification language for benefit availability. Managed care guidelines related to referral authorization, and precertification of inpatient hospitalization, home health, home infusion and hospice services apply subject to the aforementioned exceptions. DESCRIPTION Nerve Conduction Velocity Studies (NCV) measures the speed of conduction of impulses through a nerve. The impulses being measured are artificially supplied by a stimulating electrode placed on the skin over the nerve. Electrical activity in the nerve being stimulated is measured by recording electrodes placed on the skin at various distances from the stimulating electrode. The distance between the stimulating and recording electrodes and the time taken for an electrical impulse to travel between the electrodes are used to calculate the nerve conduction velocity. Nerve conduction tests have two parts testing motor and sensory nerve testing. Nerve conduction velocity studies are performed to evaluate and document a variety of sensory and motor neuropathological conditions in patients with a suspected diagnosis of nerve dysfunction. Nerve dysfunction can be manifested in decreased signal amplitude, slowed conduction velocity or increased latency. Proximal and distal nerve segments may be tested separately to help identify and localize the cause of the patient s condition. Additional tests are sometimes used to evaluate the results of treatment. Although the stimulation of nerves is similar with all NCV studies, the characteristics of motor, sensory, and mixed NCS are different. Motor NCV studies are performed by applying electrical stimulation at various points along the course of a motor nerve while recording the electrical response from an appropriate muscle. Response parameters include amplitude, latency, configuration, and motor conduction velocity. Sensory NCV studies are performed by applying electrical stimulation near a nerve and recording the response from a distant site along the nerve. Response parameters include amplitude, latency, configuration, and sensory conduction velocity. Mixed NCV studies are performed by applying electrical stimulation near a nerve containing both 1

motor and sensory fibers (a mixed nerve) and recording from a different location along that nerve that also contains both motor and sensory nerve fibers. Response parameters include amplitude, latency, configuration, and both sensory and motor conduction velocity. Another type of NCV studies is referred to as late response (H-reflex and F-wave testing) and is usually performed on nerves more proximal to the spine. These segments include the first several centimeters of a compound nerve emerging from the spinal cord or brainstem. They are helpful in diagnosing conditions of radiculopathies, plexopathies, polyneuropathies, and proximal mononeuropathies. Late response studies are additional studies complementary to NCV and are performed during the same patient evaluation. Nerve Conduction Velocity Studies (NCV) and Needle electromyography (EMG) are typically performed together, by trained and qualified practitioners. Both NCV and EMG are used for clinical diagnosis of peripheral nervous system disorders. Electromyography (EMG) is the study and recording of Intrinsic Electrical Properties of Skeletal muscles. This testing is invasive because it requires needle insertion and adjustment at multiple sites, and at anatomically critical areas. COVERAGE Benefits may vary between groups and contracts. Please refer to the appropriate member certificate and subscriber agreement contract for applicable diagnostic imaging, DME, laboratory, machine tests, benefits, and coverage. INDICATIONS I., (MCS) considers Nerve Conduction Velocity Studies (NCV) medically necessary under the following conditions: Focal neuropathies or compressive lesions such a carpal tunnel syndrome, ulnar neuropathies or root lesions, for localization Traumatic nerve lesions, for diagnosis and prognosis Diagnosis or confirmation of suspected generalized neuropathies, such as diabetic, uremic, metabolic or immune Repetitive nerve stimulation in diagnosis of Neuromuscular Junction disorders such as Myasthenia Gravis, Myasthemic Syndrome II. MCS considers Electromyography (EMG) medically necessary under the following conditions: Nerve Compression Syndromes, including carpal tunnel syndrome and other focal compressions Radiculophaty-Cervical, Lumbosacral Mononeuropathy/Polyneuropathy-Metabolic, degenerative, hereditary 2

Plexopathy-idiopathic, trauma, infiltration Myopathy-including Poly and dermatomyositis, Myotonic and Congenital Myopathies Neuromuscular Junction disorders-myasthenia Gravis (Single fiber EMG (95872) is of special value here.) III. MCS will consider Repeated Nerve Conduction Velocity Studies under the following circumstances: Repeating nerve conduction velocity studies should be based on clinical justification and there should be evidence-based documentation for any repeated study. Repeated nerve conduction velocity studies could be seen after an initial diagnosis has been made for the following conditions: a. For a patient with worsening signs and symptoms; b. For new trauma or injury to the affected area; and/or c. For a patient who is being managed medically for a condition and is not showing signs of improvement using current prescribed modalities. Repeated nerve conduction velocity studies should only be performed for conditions that require medical management and meet the coverage criteria listed in this policy. Not more than two electrodiagnostic evaluations per 12-month period are generally accepted for carpal tunnel syndrome, radiculopathy, mononeuropathy, polyneuropathy, myopathy, and neuromuscular junction disease. Not more than three electrodiagnostic evaluations in a 12-month period are generally accepted for motor neuropathy and plexopathy. CONTRAINDICATIONS/LIMITATIONS Consistent excessive use of units of testing, repeated testing on the same patient, or testing every patient referred for pain, weakness or paresthesia. The NCV-EMG performing provider, in addition to the referring provider, is responsible for determination of the appropriateness of the studies. Refer to Appendix A-Frequency of Testing; which includes the maximum of Studies permitted with medical necessity. Electrodiagnostic studies are covered when performed by providers of Neurology and Physiatrists services, or other trained providers who have a detailed knowledge of neuromuscular diseases and awareness of the influence of age, temperature, and body height on the results. Training and expertise must have been acquired within the framework of an accredited residency and/or fellowship program in the applicable specialty/subspecialty, or; If these skills have been acquired as continuing medical education, the courses must be comprehensive, offered or sponsored or endorsed by an academic institution in the United States and/or by the applicable specialty/subspecialty society in the 3

United States or Puerto Rico, and designated by the American Medical Association (AMA). Codes 95860, 95861, 95863, 95864, 95867, 95868, 95869, and 95870 require level 6a supervision, which means the service must be performed personally by the physician or a Physical therapist who is certified by the American Board of Physical Therapy Specialties (ABPTS) as a qualified electrophysiologic clinical specialist AND is permitted to provide the service under state law. Codes 95900, 95903, 95904, 95934, 95936 and 95937 require level 7a supervision which means the services must be personally performed by a physician, or by a physical therapist with (ABPTS) certification, or by a physical therapist lacking certification but under the direct supervision of a Physician, or by a technician with a certification under the general supervision of a physician. Segmental testing of a single nerve represents a single study. For example, a test of the ulnar nerve at wrist, forearm, below elbow, above elbow, axilla, and supraclavicular regions represents one test. Similarly, the use of different methods of measuring the conduction in the same nerve, such as orthodromic and antidromic testing, constitutes one study. The number of tests (units of each CPT code) performed should be the minimum needed to establish an accurate diagnosis. On a particular day of testing, the number of tests performed/nerves tested should not exceed the number of tests/nerves indicated in the table Appendix A-Frequency of Testing, and exceptions may result in medical review. Categorically, there are general standards accepted for repeat electrodiagnostic testing in certain categories of diseases. Not more than two electrodiagnostic evaluations per 12-month period are generally accepted for carpal tunnel syndrome, radiculopathy, mononeuropathy, polyneuropathy, myopathy, and neuromuscular junction disease. Not more than three electrodiagnostic evaluations in a 12-month period are generally accepted for motor neuropathy and plexopathy. Therefore, repeat electrodiagnostic testing should not be needed in a 12-month period in the majority of all cases. Documentation should be available to verify the need for repeat testing on any patient. Note: Sensory Nerve Conduction Threshold Test (snct) is not considered medically necessary by MCS. All uses of snct to diagnose sensory neuropathies or radiculopathies are not considered medically necessary. MCS considers the following to be experimental and investigational: Examination/NCV studies using the NC-stat monitor, the Brevio NCS monitor, the Neural-Scan, and other automated devices are considered experimental and investigational. 4

NCV studies are considered experimental and investigational for screening for polyneuropathy of diabetes or end-stage renal disease. CODING INFORMATION CPT Codes for Nerve Conduction Velocity Studies (NCS) CPT Codes DESCRIPTION 95900 Nerve Conduction, amplitude and latency/velocity study. Each nerve; motor, without F-wade study 95903 Nerve Conduction, amplitude and latency/velocity study, each nerve motor, with F- wade study 95904 Nerve Conduction, amplitude and latency/velocity study, each nerve; sensory 95905 Motor and/or sensory nerve conduction, using preconfigured electrode array(s), amplitude and latency/velocity study, each limb, includes F-wave study when performed, with interpretation and report 95934 H-reflex, amplitude and latency study; record gastrocnemius/soleus muscle 95936 H-reflex, amplitude and latency study; record muscle other than gastrocnemius/soleus muscle 95937 Neuromuscular junction testing (Repetitive stimulation, paired stimuli), each nerve, any one method *Current Procedural Terminology (CPT ) 2011 American Medical Association: Chicago, IL. CPT Codes for Electromyography (EMG) CPT Codes DESCRIPTION 95860 Needle electromyography; one extremity with or without related paraspinal areas 95861 Needle electromyography; two extremities with or without related paraspinal areas 95863 Needle electromyography; three extremities with or without related paraspinal areas 95864 Needle electromyography; Four extremities with or without related paraspinal areas 95867 Needle electromyography; Cranial Nerve supplied Muscle(s), Unilateral 5

95868 Needle electromyography, Cranial Nerve Supplied Muscles, Bilateral 95869 Needle Electromyography; Thoracic Paraspinal Muscles (Excluding T1 or T2) 95870 Needle Electromyography; Limited study of Muscle in One Extremity or Non-Limb (Axial) Muscles (Unilateral or Bilateral), other than thoracic Paraspinal, cranial nerve supplied muscles, or sphinters 95872 Needle electromyography using single fiber electrode, with quantitative measurement of Jitter, Blocking and/or fiber density, any/all sites of each muscle studied *Current Procedural Terminology (CPT ) 2011 American Medical Association: Chicago, IL. ICD-9 CM Diagnosis Codes ICD-9 CM CODES DESCRIPTION 192.2 MALIGNANT NEOPLASM OF SPINAL CORD 192.3 MALIGNANT NEOPLASM OF SPINAL MENINGES 198.3 SECONDARY MALIGNANT NEOPLASM OF BRAIN AND SPINAL CORD 198.4 SECONDARY MALIGNANT NEOPLASM OF OTHER PARTS OF NERVOUS SYSTEM 250.60-250.63 DIABETES WITH NEUROLOGICAL MANIFESTATIONS, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED - DIABETES WITH NEUROLOGICAL MANIFESTATIONS, TYPE I [JUVENILE TYPE], UNCONTROLLED 265.1 OTHER AND UNSPECIFIED MANIFESTATIONS OF THIAMINE DEFICIENCY 269.1 DEFICIENCY OF OTHER VITAMINS 335.0-335.9 336.0-336.9 WERDNIG-HOFFMANN DISEASE - ANTERIOR HORN CELL DISEASE UNSPECIFIED SYRINGOMYELIA AND SYRINGOBULBIA - UNSPECIFIED DISEASE OF SPINAL CORD 337.00 IDIOPATHIC PERIPHERAL AUTONOMIC NEUROPATHY, UNSPECIFIED 337.01 CAROTID SINUS SYNDROME 6

337.09 OTHER IDIOPATHIC PERIPHERAL AUTONOMIC NEUROPATHY 337.20-337.29 REFLEX SYMPATHETIC DYSTROPHY UNSPECIFIED - REFLEX SYMPATHETIC DYSTROPHY OF OTHER SPECIFIED SITE 337.3 AUTONOMIC DYSREFLEXIA 340 MULTIPLE SCLEROSIS 341.0-341.9 344.00-344.9 350.1-350.9 NEUROMYELITIS OPTICA - DEMYELINATING DISEASE OF CENTRAL NERVOUS SYSTEM UNSPECIFIED QUADRIPLEGIA UNSPECIFIED - PARALYSIS UNSPECIFIED TRIGEMINAL NEURALGIA - TRIGEMINAL NERVE DISORDER UNSPECIFIED 351.0 BELL'S PALSY 351.8 OTHER FACIAL NERVE DISORDERS 352.3 DISORDERS OF PNEUMOGASTRIC (10TH) NERVE 352.4 DISORDERS OF ACCESSORY (11TH) NERVE 352.5 DISORDERS OF HYPOGLOSSAL (12TH) NERVE 352.6 MULTIPLE CRANIAL NERVE PALSIES 353.0 BRACHIAL PLEXUS LESIONS 353.1 LUMBOSACRAL PLEXUS LESIONS 353.2 CERVICAL ROOT LESIONS NOT ELSEWHERE CLASSIFIED 353.3 THORACIC ROOT LESIONS NOT ELSEWHERE CLASSIFIED 353.4 LUMBOSACRAL ROOT LESIONS NOT ELSEWHERE CLASSIFIED 353.5 NEURALGIC AMYOTROPHY 354.0-354.9 CARPAL TUNNEL SYNDROME - MONONEURITIS OF UPPER LIMB UNSPECIFIED 7

355.0-355.9 LESION OF SCIATIC NERVE - MONONEURITIS OF UNSPECIFIED SITE 356.0-356.9 357.0-357.9 358.00-358.01 HEREDITARY PERIPHERAL NEUROPATHY - UNSPECIFIED IDIOPATHIC PERIPHERAL NEUROPATHY ACUTE INFECTIVE POLYNEURITIS - UNSPECIFIED INFLAMMATORY AND TOXIC NEUROPATHIES MYASTHENIA GRAVIS WITHOUT (ACUTE) EXACERBATION - MYASTHENIA GRAVIS WITH (ACUTE) EXACERBATION 358.1* MYASTHENIC SYNDROMES IN DISEASES CLASSIFIED ELSEWHERE 359.0-359.9 CONGENITAL HEREDITARY MUSCULAR DYSTROPHY - MYOPATHY UNSPECIFIED 368.2 DIPLOPIA 378.73 STRABISMUS IN OTHER NEUROMUSCULAR DISORDERS 710.4 POLYMYOSITIS 721.0-721.91 CERVICAL SPONDYLOSIS WITHOUT MYELOPATHY - SPONDYLOSIS OF UNSPECIFIED SITE WITH MYELOPATHY 722.4 DEGENERATION OF CERVICAL INTERVERTEBRAL DISC 722.51-722.52 722.80-722.83 DEGENERATION OF THORACIC OR THORACOLUMBAR INTERVERTEBRAL DISC - DEGENERATION OF LUMBAR OR LUMBOSACRAL INTERVERTEBRAL DISC POSTLAMINECTOMY SYNDROME OF UNSPECIFIED REGION - POSTLAMINECTOMY SYNDROME OF LUMBAR REGION 723.1 CERVICALGIA 723.4 BRACHIAL NEURITIS OR RADICULITIS NOS 724.2 LUMBAGO 724.3 SCIATICA 724.4 THORACIC OR LUMBOSACRAL NEURITIS OR RADICULITIS UNSPECIFIED 8

728.2 MUSCULAR WASTING AND DISUSE ATROPHY NOT ELSEWHERE CLASSIFIED 728.85 SPASM OF MUSCLE 728.87 MUSCLE WEAKNESS (GENERALIZED) 729.5 PAIN IN LIMB 729.71 NONTRAUMATIC COMPARTMENT SYNDROME OF UPPER EXTREMITY 729.72 NONTRAUMATIC COMPARTMENT SYNDROME OF LOWER EXTREMITY 736.05 WRIST DROP (ACQUIRED) 736.79 OTHER ACQUIRED DEFORMITIES OF ANKLE AND FOOT 780.79 OTHER MALAISE AND FATIGUE 781.2 ABNORMALITY OF GAIT 781.3 LACK OF COORDINATION 781.4 TRANSIENT PARALYSIS OF LIMB 782.0 DISTURBANCE OF SKIN SENSATION 787.20-787.29 952.00-952.09 952.10-952.19 DYSPHAGIA, UNSPECIFIED - OTHER DYSPHAGIA C1-C4 LEVEL SPINAL CORD INJURY UNSPECIFIED - C5-C7 LEVEL WITH OTHER SPECIFIED SPINAL CORD INJURY T1-T6 LEVEL SPINAL CORD INJURY UNSPECIFIED - T7-T12 LEVEL WITH OTHER SPECIFIED SPINAL CORD INJURY 952.2 LUMBAR SPINAL CORD INJURY WITHOUT SPINAL BONE INJURY 952.3 SACRAL SPINAL CORD INJURY WITHOUT SPINAL BONE INJURY 952.4 CAUDA EQUINA SPINAL CORD INJURY WITHOUT SPINAL BONE INJURY 952.8 MULTIPLE SITES OF SPINAL CORD INJURY WITHOUT SPINAL BONE INJURY *2011 ICD-9-CM For Physicians, VOLUMES I & II, Professional Edition (American Medical Association) * According to the 2007 ICD-9-CM book, diagnosis code 358.1 is a manifestation code and not allowed to be reported as a primary diagnosis code. 9

HCPCS CODES NOT COVERED HCPCS CODES DESCRIPTION G0255 CURRENT PERCEPTION THRESHOLD/SENSORY NERVE CONDDUCTION TEST,(SNCT) PER LIMB, ANY NERVE S3905 NON-INVASIVE ELECTRODIAGNOSTIC TESTING WITH AUTOMATIC COMPUTERIZED HAND-HELD DEVICE TO STIMULATE AND MEASURE NEUROMUSCULAR SIGNALS IN DIAGNOSING AND EVALUATING SYSTEMIC AND ENTRAPMENT NEUROPHATHIES *2011 HCPCS LEVEL II Professional Edition (American Medical Association). REFERENCES 1. American Association of Neuromuscular & Electrodiagnostic Medicine (AANEM), Proper Performance and Interpretation of Electrodiagnostic Studies. September 2005. www.aanem.org/practiceissues/positionstatement/positionstatments.cfm 2. American Association of Neuromuscular & Electrodiagnostic Medicine (AANEM), Recommended Policy for Electrodiagnostic Medicine. Endorsed by the American Academy of Neurology. The American Academy of Physical Medicine and Rehabilitation and the American Association of Neuromuscular and Electrodiagnostic Medicine. www.aanem.org/practiceissues/recpolicy/recommended_policy_1.cfm 3. American Association of Neuromuscular and Electrodiagnostic Medicine (AAEM), Who is qualified to practice electrodiagnostic medicine. Position statement. Approved May 1999. www.aanem.org/practiceissues/positionstatements/who%27s_qualified.cfm 4. First Coast Service Options, Inc. LCD for Electromyography and Nerve Conduction Studies (L29325). Determination Effective Date: 1/1/2010. Last review 06/14/2011. Accessed 11/03/2011. No changes for medical Indications. Available at http://www.cms.gov/medicarecoverage-database/license/cptlicense.aspx?from=http*3a%24%2f%2fwww.cms.gov%2fmedicare-coveragedatabase%2findexes%2flcdlist.aspx%3fcntrctr%3d198%26contrver%3d1%26cntrctrselected%3d198*1%26name%3dfirst% 2bCoast%2bService%2bOptions%2c%2bInc.%2b(09202%2c%2bMAC%2b- %2bPart%2bB)%26s%3d46%26bc%3dAggAAAAAAAAA%26&npage=/medicare-coveragedatabase/details/lcddetails.aspx&LCDId=29325&ContrId=198&ver=8&ContrVer=1&CntrctrSelected=198*1&Cntrctr= 198&name=First+Coast+Service+Options%2c+Inc.+(09202%2c+MAC+- +Part+B)&s=46&bc=AggAAAIAAAAA& 10

5. NCS System. NeuroMetrix. Nerve Conduction on Studies. 2008. 6. www.ecri.org. Point of Care Nerve Conduction Tests. Published: 05/02/2007. POLICY HISTORY DATE ACTION COMMENT November 5, 2009 Origination of Policy November 5, 2010 Yearly Review Added code 95905 November 2, 2011 Yearly Review This document is for informational purposes only. It is not an authorization, certification, explanation of benefits, or contract. Receipt of benefits is subject to satisfaction of all terms and conditions of coverage. Eligibility and benefit coverage are determined in accordance with the terms of the member s plan in effect as of the date services are rendered., (MCS) medical policies are developed with the assistance of medical professionals and are based upon a review of published and unpublished information including, but not limited to, current medical literature, guidelines published by public health and health research agencies, and community medical practices in the treatment and diagnosis of disease. Because medical practice, information, and technology are constantly changing, Medical Card System, Inc., (MCS) reserves the right to review and update its medical policies at its discretion, (MCS) medical policies are intended to serve as a resource to the plan. They are not intended to limit the plan s ability to interpret plan language as deemed appropriate. Physicians and other providers are solely responsible for all aspects of medical care and treatment, including the type, quality, and levels of care and treatment they choose to provide. APPENDIX A-Frequency of Testing The following table lists the American Association of Neuromuscular & Electrodiagnostic Medicine's (formerly known as American Association of Electrodiagnostic Medicine) recommendations concerning a reasonable maximum number of NCV studies, needle EMG and other EMG studies per diagnostic category needed for a physician to render a diagnosis. Each number in the Maximum Number of Studies Table represents 1 study or Unit. Table : Maximum Number of Studies Needle Electromyography, CPT 95860-95864 and Nerve Conduction Studies CPT 95900, Other Electromyographic Studies CPT 95934, 95936, 11

95867-95870 95903, 95904 95937 Indications Number of Services (Tests) Motor NCS with And/or without F wave Sensory NCS H- Reflex Neuromuscular Junction Testing (Repetitive Stimulation) Carpal Tunnel (Unilateral) 1 3 4 - - Carpal Tunnel (Bilateral) 2 4 6 - - Radiculopathy 2 3 2 2 - Mononeurophathy 1 3 3 2 - Polyneuropathy/Mononeuropathy Multiplex 3 4 4 2 - Myopathy 2 2 2-2 Motor Neuronopathy (e.g., ALS) 4 4 2-2 Plexopathy 2 4 6 2 - Neuromuscular Junction 2 2 2 3 Tarsal Tunnel Syndrome (Unilateral) 1 4 4 - - Tarsal Tunnel Syndrome (Bilateral) 2 5 6 - - Weakness, Fatigue, Cramps, or Twitching (focal) Weakness, Fatigue, Cramps, or Twitching (General) 2 3 4-2 4 4 4 2 Pain, Numbness, or Tingling (Unilateral) 1 3 4 2 - Pain, Numbness, or Tingling (Bilateral) 2 4 6 2-12